Whenever I get a letter from Blue Cross Blue Shield of Massachusetts that begins, “Dear Business Partner:” I know to be wary. Inevitably it starts something like the letter I received today:
We are committed to improving the affordability of health care by facilitating the appropriate use of health care services.
…and then goes on to describe a benefit that’s being reduced or eliminated. In this case it’s four benefits.
For starters, calling my boutique consulting firm a “Business Partner” is a bit of a stretch. We are fully insured, so we are really just a customer of BCBSMA. I have a hard time imagining we are looked at as anything other than that.
These letters do provide some insight into where costs are rising, so they are somewhat instructive from a health wonk standpoint. Here’s what today’s communication announces:
- Prior authorization for hip replacement surgeries
- Prior authorization for knee replacement surgeries
- Prior authorization for sleep studies
- Prior authorization for neuropsychological testing
Here’s my speculation as to what’s going on:
- Hip and knee replacement devices are continuing to improve, to the point that younger and younger people are considering them. I know people in their mid-40s whose knees aren’t what they were. Some are considering knee replacements with the hope of getting back to the ski slopes. This wouldn’t have happened a few years ago but the combination of better, longer-lasting technology and consumer directed advertising and marketing on the part of device makers and orthopods is now having an impact on the commercial market, rather than just affecting the Medicare segment. These surgeries are pricey. This change doesn’t bother me too much.
- A couple years ago a physician friend gave me a business idea: get involved with the sleep center business, which he expected to grow rapidly. In his view, the increase in obesity was contributing to an increase in sleep apnea, and he felt there were many patients out there with undiagnosed sleep problems that were a factor in their overall health. Sounds like he was right. I’m not sure exactly what the medical rationale is for BCBSMA on this one. Interestingly, the letter notes that “Blue Cross Blue Shield of Massachusetts medical policy will be used in reviews for sleep studies,” whereas InterQual’s evidence based guidelines will be used for the other prior auth categories. I’m a bit dubious of this change.
- The prior auth requirements for neuropsych testing appear to be aimed at reducing the use of such tests for ADHD and for educational or vocational improvement. “Authorization of ADHD testing will only be considered if there are well-documented signs or symptoms that can be attributed to more than one condition, for which neuropsychological testing can offer a clear resolution. Neuropsychological testing for the routine diagnosis of ADHD is not regarded as medically necessary and, therefore, will not be authorized. Testing solely for education or vocational purposes is not a covered benefit.” Reading between the lines on this one my sense is that the ADHD rule is a change of policy and that BCBS MA is trying to limit neuro psych testing for school or job performance that occurs under the guise of diagnosing ADHD. I know the demand for neuro psych evals is high. As I’ve written, it’s actually impossible to schedule an appointment for neuro-pscyh evaluation at Children’s Hospital in Boston.